Inspection Details

Inspection #
INSP-0058228
Inspection Date(s)
4/30/2024
Status
Complete
Inspection Type
Compliance (Annual)
Worksheet Type
Assisted Living Home
Certificate Number
AL9568H
Location Type
โ€”

Initial Comments

The following deficiencies were found during the on-site compliance inspection conducted on April 30, 2024:

Statement of Deficiency

2 deficiencies found
Deficiency #1
✓ Plan Provided
Rule
A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;
Evidence
Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. Review of the April 2024 personnel schedule revealed two shifts; 6am -6pm (day shift) and 6pm - 6am (night shift). 2. Review of the facility's employee disaster drills revealed the most current disaster drill conducted December 1, 2023 on the day shift and night shift. No other employee disaster drills were available after December 1, 2023. 3. In an interview, E2 acknowledged the employee disaster drills were not conducted on each shift at least once every three months.
Plan of Correction
Permanent Correction Date
2024-06-10
Deficiency #2
✓ Plan Provided
Rule
A. A manager shall ensure that: 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and
Evidence
Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement the evacuation plan. Findings include: 1. Review of the facility's employee and resident evacuation drills revealed the most current drill conducted September 1, 2023. No other employee and resident evacuation drills were available after September 1, 2023. 2. In an interview, E2 acknowledged the employee and resident evacuation drills were not conducted at least once every six months.
Plan of Correction
Permanent Correction Date
2024-06-10